Dynamic Article: Full-Thickness Excision for Benign Colon Polyps Using Combined Endoscopic Laparoscopic Surgery

Intraoperative localization of gastrointestinal tumors by magnetic tracer technique during laparoscopic-assisted surgery (with video)

BACKGROUND

Laparoscopic localization of gastrointestinal tumors has long been an important objective. This study aimed to evaluate the clinical application of a magnetic tracer technique during laparoscopic-assisted surgery.

METHODS

Fifty-seven patients with gastrointestinal tumors, who voluntarily underwent endoscopic marking between May 2019 and May 2020, were enrolled. A magnetic ring was clamped onto tissues adjacent to the lesion and released during preoperative endoscopy. Then, another magnet ring or laparoscopic instrument was delivered to the wall of the digestive tract contralateral to the lesion and attracted, thus achieving accurate intraoperative localization. Observational evaluation included data regarding preoperative marking, intraoperative localization, operation, and safety.

RESULTS

Fifty-six of the 57 (98.2%) patients with gastric tumors (n = 35), duodenal tumors (n = 1), and colorectal tumors (n = 20), successfully underwent marking, localization, and resection. The mean margins of proximal and distal resection of colorectal tumors were 106 and 78 mm, respectively. The mean (± SD) duration of endoscopic marking and laparoscopic localization for gastric/duodenal and colorectal tumors were 5.3 ± 0.3, 1.0 ± 0.1, 5.5 ± 0.4, and 1.0 ± 0.1 min, respectively. No complications occurred in 56 of the 57 patients.

CONCLUSIONS

The magnetic tracer technique demonstrated promising potential as a localization method for gastrointestinal tumors, with superior safety, effectiveness, rapidity, and convenience.

Current Status and Prospects of Endoscopic Resection Technique for Colorectal Tumors

Currently, endoscopic submucosal dissection (ESD) is a well-established and common treatment for intramucosal colorectal cancer in Japan. However, colorectal ESD is technically more difficult to perform than esophageal and gastric ESD, and some lesions, such as fibrotic lesions, are difficult to dissect by endoscopy. Several techniques, such as the pocket-creation method and laparoscopically assisted endoscopic polypectomy, have been utilized for challenging targets. In recent years, endoscopic full-thickness resection (EFTR) using full-thickness resection devices have mainly been performed in Western countries. We have used laparoscopy and endoscopy cooperative surgery for colorectal tumors (LECS-CR) since 2011 for the challenging treatment of colorectal ESD. Improvements in ESD techniques have resulted in an increase in the literature on EFTR, and LECS-CR may be considered an effective endoscopic technique for colorectal ESD in the future.

Combined Endoscopic-Robotic Resection of a Giant Polyp to Avoid Colorectal Resection

Colorectal cancer prevention relies on effective screening through colonoscopy and polypectomy. Several techniques and methods have been described to manage complex colonic polyps such as the ones that are endoscopically unresectable. Across time, we have been able to perform less invasive techniques that include different types of colonic resections, ranging from partial thickness, full-thickness and, segmental colectomies, however, none has proven to be the treatment of choice for these lesions. The technique presented here is an attractive alternative to segmental colectomy using a robotic platform to perform a full-thickness resection.

Referrals for surgical removal of polyps since the introduction of a colorectal cancer screening programme

AIM

Implementation of the Dutch national bowel screening programme in 2014 led to an increased rate of detection of polyps. In general, polyps should be removed endoscopically. However, if the size and location of the polyp make endoscopic removal technically difficult, or if there is a suspicion for early (T1) cancer, surgery is the preferred method for removal. An increasing number of these patients are being treated with minimally invasive surgical procedures instead of segmental resection. The aim of this study was to assess the number of referrals for surgery and the type of surgery for polyps since the introduction of the Dutch national bowel screening programme.

METHOD

A retrospective cohort study was performed. Patients who underwent surgery for colorectal polyps between January 2012 and December 2017 were included. Patients with histologically proven carcinoma prior to surgery were excluded. Primary outcomes were the number and type of surgical procedures for polyps.

RESULTS

A total of 164 patients were included. An annual increase in procedures for colorectal polyps was observed, from 18 patients in 2012 to 36 patients in 2017. All the procedures before implementation of the screening programme were segmental resections, and 58.8% of the patients underwent organ-preserving surgery after implementation of the screening. The overall complication rate of organ-preserving surgery was 16.3%, compared with 44.3% for segmental resections (P = 0.001). Overall, invasive colorectal cancer was encountered in 23.8% of cases.

CONCLUSION

The number of referrals for surgical resection of colorectal polyps has doubled since the introduction of the Dutch national bowel screening programme with a substantial shift towards organ-preserving techniques.

Combined endo-laparoscopic surgery for difficult benign colorectal polyps

Prevention of colorectal cancer (CRC) depends largely on the detection and removal of colorectal polyps. Despite the advances in endoscopic techniques, there are still a subgroup of polyps that cannot be treated purely by endoscopic approach, which comprise of about 10-15% of all the polyps. These so-called "difficult colorectal polyps" are polyps with large size, morphology, at difficult location, scarring or due to recurrence, which have historically been managed by surgical segmental resection. In treating benign difficult colorectal polyps, we have to balance the operative risks and morbidities associated with surgical segmental resection. Therefore, combined endoscopic and laparoscopic surgery (CELS) has been developed to remove this subgroup of difficult benign polyps. We review the currently use of CELS for difficult benign colorectal polyps which includes laparoscopy-assisted endoscopic polypectomy (LACP), full-thickness laparo-endoscopic excision (FLEX) and colonoscopy-assisted laparoscopic wedge resection (CAL-WR).

Evaluation of an early-stage innovation for full-thickness excision of benign colonic polyps using the IDEAL framework

AIMS

Colectomy is the current approach for patients with endoscopically unresectable benign polyps but risks considerable morbidity. Full-thickness laparoendoscopic excision (FLEX) is a novel procedure, specifically developed to treat endoscopically unresectable benign colonic polyps, which could reduce the treatment burden of the current approach and improve outcomes. However, traditional evaluations of surgical innovations lack methodological rigour. This study reports the development and feasibility of the FLEX procedure in selected patients.

METHOD

A prospective development study using the Idea, Development, Evaluation, Assessment, Long-term study (IDEAL) framework was undertaken, by one surgeon, of the FLEX procedure in selected patients with endoscopically unresectable benign colonic polyps. Three-dimensional (3D)-CT colonography reconstructions were used preoperatively to rehearse patient-specific, critical manoeuvres. Targetted, full-thickness excision was performed: after marking the margin of the caecal polyp using circumferential endoscopic argon plasma coagulation, transmural endoscopic sutures were used to evert the bowel and resection was undertaken by laparoscopic linear stapling. Feasibility outcomes (establishing 'local success') included evidence of complete polyp resection without adverse events (especially safe closure of the excision site).

RESULTS

Ten patients [median (interquartile range) age: 74 (59-78) years] with polyp median diameters of 35 (30-41) mm, were referred for and consented to receive the FLEX procedure. During the same time frame, no patient underwent colectomy for benign polyps. One further patient received FLEX for local excision of a presumed malignant polyp because severe comorbidity prohibited standard procedures. The FLEX procedure was successfully performed locally, with complete resection of the polyp and safe closure of the excision site, in eight patients. Three noncompleted procedures were converted to laparoscopic segmental colectomy under the same anaesthetic because of endoscopic inaccessibility (two patients) and transcolonic suture failure (one patient).

CONCLUSIONS

The FLEX procedure is still under development. Early data demonstrate that it is safe for excision of selected benign polyps. Modifications to transcolonic suture delivery are now required and there is a need for wider adoption before more definitive evaluation can be performed.

Quality of endoscopy reporting at index colonoscopy significantly impacts outcome of subsequent EMR in patients with > 20 mm colon polyps

Background and study aims  Endoscopic mucosal resection (EMR) is safe and cost-effective in management of patients with colon polyps. However, very little is known about the actions of the referring endoscopist following identification of these lesions at index colonoscopy, and the impact of those actions on the outcome of subsequent referral for EMR. The aim of this study was to identify practices at index colonoscopy that lead to failure of subsequent EMR. Patients and methods  Two hundred and eighty-nine consecutive patients with biopsy-proven non-malignant colon polyps (> 20 mm) referred for EMR were analyzed to identify practices that could be improved from the time of identifying the lesion at index colonoscopy until completion of therapy. Results  EMR was abandoned at colonoscopy at the EMR center in 71 of 289 patients (24.6 %). Reasons for abandoning EMR included diagnosis of invasive carcinoma (n = 9; 12.7 %), tethered lesions (n = 21; 29.6 %) from prior endoscopic interventions, and overly large (n = 22; 31 %) and inaccessible lesions (n = 17; 24 %) for complete and safe resection whose details were not recorded in the referring endoscopy report, or polyposis syndromes (n = 2; 2.8 %) that were not recognized. Conclusions  In our practice, one in four EMR attempts were abandoned as a result of inadequate diagnosis or management by the referring endoscopist, which could be improved by education on optical diagnosis of polyps, comprehensive documentation of the procedure and avoidance of interventions that preclude resection.

The Difficult Colorectal Polyp

Difficult colorectal polyps represent lesions that pose a challenge to traditional endoscopic snare polypectomy. These polyps have historically been managed by surgical resection. Currently, several less invasive options are available to avoid colectomy. Repeat colonoscopy and snare polypectomy by an expert endoscopist, endoscopic mucosal resection, endoscopic submucosal dissection, and combined endoscopic and laparoscopic surgery have been developed to remove difficult polyps without the need for formal surgical resection. Patients with rectal polyps have the advantage of additional transanal minimally invasive techniques to enhance their resectability. Today, most colorectal polyps can be managed without the need for formal surgical resection.

Combined Endoscopic Laparoscopic Surgery Procedures for Colorectal Surgery

Colonoscopy is the standard of care for screening and surveillance of colorectal cancers. Removal of adenomatous polyps prevents the transformation of adenomas to potential adenocarcinoma. While most polyps are amenable to simple endoscopic polypectomy, difficult polyps that are large, broad-based, or located in haustral folds or in tortuous colon segments can present a challenge for endoscopists. Traditionally, patients with endoscopically unresectable polyps have been referred for oncologic surgical resection due to the underlying risk of malignancy within the polyp; however, the majority of these polyps are benign on final pathology. Combined endoscopic laparoscopic surgery can help facilitate endoscopic removal of difficult lesions, or allow the surgeon to select the correct laparoscopic approach for polyp excision. Current literature suggests that these procedures are safe and effective and can potentially save patients from the morbidity of laparotomy and segmental colectomy.

Limited Endoscopic-Assisted Wedge Resection for Excision of Colon Polyps

BACKGROUND

Combined endoscopic laparoscopic surgical removal is used for polyps in the colon that are not suitable for endoscopic removal because of size, location, or scarring. However, the placement of a linear stapler can be challenging. Currently a wedge resection is mostly documented in the cecum or ascending colon.

OBJECTIVE

We report on our experience with limited endoscopy-assisted wedge resections in the entire colon.

DESIGN

A retrospective study was performed.

SETTINGS

This was a single-center study.

PATIENTS

Eight patients were included between March 2015 and April 2016.

INTERVENTIONS

The laparoscopic surgical technique consisted of placing a suture under endoscopic view through the base of the polyp into the lumen. Subsequently, traction was given on the suture to enable stapling of a wedge of the colon.

MAIN OUTCOME MEASURES

Medical data were collected (ie, indication for referral for surgery, location and size of the polyp, duration of surgical procedure, length of hospital stay, and perioperative and postoperative complications). Operative time was defined as the total time of general anesthesia.

RESULTS

Eight patients, with a mean age of 74.5 years (range, 68.0-82.0 years), were treated. The main indications for laparoscopic resection were the size and difficult location of the polyp. There were no complications. Mean operative time was 132 minutes. Five patients were discharged the day after surgery, and the other 3 patients were admitted for a total of 2 days.

LIMITATIONS

The study was limited by its small sample size.

CONCLUSIONS

Our study found that limited endoscopy-assisted wedge resection is a feasible and easy technique for the removal of colon polyps and residual adenomatous tissue in scars that are not accessible for endoscopic removal. Because of traction given on the suture through the base of the polyp, the linear stapler is easily used for wedge resections of polyps, even for those that are not in favorable positions.